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Province not given full story in outbreak

Canada's food safety agency withheld crucial information from the provincial health ministry during last summer's listeria outbreak that could have reduced a deadly risk to Ontarians, says the province's chief medical officer of health.

Maple Leaf staff show revamped cleaning methods at North York plant in December 2008 in aftermath of listeria crisis. (STEVE RUSSELL / TORONTO STAR FILE PHOTO)

Canada's food safety agency withheld crucial information from the provincial health ministry during last summer's listeria outbreak that could have reduced a deadly risk to Ontarians, says the province's chief medical officer of health.

"Although the (Ontario) Ministry of Health ... asked the (Canadian Food Inspection Agency) for comprehensive information on the distribution of the products implicated in the outbreak, this information was never received," says the report by Dr. David Williams.

"If public health authorities had had timely access to this information, they might have been able to take additional targeted steps to reduce possible exposure among the general public."

The listeria outbreak, which was traced to cold cuts produced in a North York Maple Leaf Foods plant, killed 21 people and sickened hundreds – perhaps thousands – more.

That human toll was exacerbated by poor communications between health officials, Ontario laboratories unequipped to handle the scientific detective work needed to trace the source of the outbreak and a communication strategy that produced "public confusion," Williams' report concludes.

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In the frantic rush last August to locate the source of the outbreak and remove it from the marketplace, Williams' ministry was unable to get basic information from the CFIA on the number of food establishments that had received suspect Maple Leaf cold cuts or their locations, he said.

While signs of the outbreak began emerging in mid-July, the province's health ministry wasn't informed until Aug. 14 that contaminated meat had been distributed to restaurants. It took three more days to learn potentially tainted Maple Leaf cold cuts had also made their way into retail stores and deli counters, Williams says.

"If I had known these products had gone out to the general public I would have recommended a wider recall sooner. Our information was, up until the time I had the press conference, it had only gone to these large institutional providers."

As a result, the province didn't issue a general health advisory to the public until Aug. 20.

By that time, people were dying.

Toronto's medical officer of health, Dr. David McKeown, says his agency asked the CFIA to send its inspectors into the Maple Leaf plant on Aug. 26. The CFIA asked for the request in writing, he said. City inspectors didn't get inside the plant for another five days.

"You would think that if there were comprehensive and effective arrangements in place, then it should be easy to work together and we shouldn't have had to submit a request in writing," McKeown said. "I don't think the co-ordination issues raised have been fixed yet."

Tim O'Connor, a spokesperson for the CFIA, said the agency will "consider all recommendations" presented to it from federal and provincial authorities.

In a CFIA "lessons learned" report on the listeria crisis issued yesterday, the agency gives itself high marks for partnering with other agencies, saying there was "good co-operation between the CFIA and provincial jurisdictions during a sampling blitz in Ontario."

The rosy self-assessment also concludes the agency "provided timely and comprehensive notification to the public."

Williams' report takes a very different view.

"The lack of co-ordination contributed to public confusion and created the impression that the outbreak was not being well managed, which affected public trust and confidence in the public health system," the provincial report says.

He fingers the Public Health Agency of Canada for not having "a clear mandate for leadership."

In its own report also issued yesterday, the Public Health Agency dismisses that claim, saying it "demonstrated a strong federal leadership role during the listeriosis outbreak."

Williams' report also says the listeria investigation was hampered because meat samples had to be shipped to national laboratories in Ottawa and Winnipeg for testing. That time-sensitive verification work couldn't be done in a local provincial lab because it was ill equipped to handle the task even after the 2003 SARS outbreak.

When two people in the same Toronto nursing home died in mid-July, local inspectors collected samples of the food and sent it for testing on July 21. It took two weeks to get the results from a federal Ottawa lab.

That delay could have been shortened – and the investigation sped up – if the testing could have been done locally, the report concludes.

Dr. Vivek Goel, president and CEO of the Ontario Agency for Health Protection and Promotion, which operates the province's public health labs, said his agency is engaged in a multi-year project to "transform a public health lab system that quite honestly, at the time of SARS, had been decimated."

Many of the recommendations made in the report for the OAHPP were in the process of being implemented before the outbreak, he said. He expects most of the work needed to meet the recommendations will be completed in two to three years.

"So there are obvious things that we have either acted on or are moving on right away. But again there is a much larger aspect to transforming this lab system that has really fallen behind over the last 20 or 30 years and you don't turn that around on a dime."

"I think there's a lot of blame laid here at the federal government and lots of questions that need to be answered."

Malcolm Allen, NDP deputy agriculture critic, said the lack of co-ordination and confusion was evident even during the outbreak.

"In outbreaks, people look to the health department to ask, 'What should we do?' They weren't getting those answers. Where was the spokesperson for the government? Where was the CFIA?

"The key figure in all of this was the CEO of a corporation (Maple Leaf CEO Michael McCain)."

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